Evidence is mounting that e-cigarettes are exposing a new generation to nicotine addiction and may be leading users toward a cigarette habit. As a result, the U.S. surgeon general last month issued a report declaring youth e-cigarette use “a major public health concern.”

“All Americans need to know that e-cigarettes are dangerous to youth and young adults,” said Surgeon General Vivek Murthy, in releasing the report. “Any tobacco use, including e-cigarettes, is a health threat, particularly to young people.”

The battery-powered devices heat a liquid typically containing nicotine mixed with the chemicals propylene glycol and glycerin as well as flavorings to deliver an aerosol inhaled by the user. While e-cigarettes deliver nicotine without the tar and smoke of traditional tobacco cigarettes, they still are considered tobacco products.

But their healthy halo has helped propel their popularity: E-cigarettes are now so popular that more American youth vape than smoke cigarettes. In just a decade, e-cigarettes have become a multibillion-dollar business led by multinational tobacco companies with outlets not just online but everywhere from vape shops to convenience stores and retail giants like Wal-Mart.

Ads tout them as a cool, harmless alternative to cigarettes. E-cigarette users, or vapers, have contests to see who can blow the largest cloud of vapor.

But there’s more to e-cigarettes than meets the eye. The surgeon general’s report aligns with increasing scrutiny of e-cigarettes, from new regulations to a growing body of research into health effects.

Here are 10 things to know about e-cigarettes:

E-cigarettes contain nicotine

E-cigarettes contain nicotine, which is addictive and can harm the developing adolescent brain, said UC San Francisco professor of medicine Stanton Glantz.

A lot of the kids who take up vaping are at low risk for smoking, but once they start using e-cigarettes, they are three to four times more likely to start using cigarettes, Glantz said.

“The biggest health concern with e-cigarettes is they are prolonging and expanding the tobacco industry,” Glantz said.

Glantz, director of UCSF’s Center for Tobacco Control Research and Education, said he was initially neutral on e-cigarettes, but now finds them concerning. Among other hazards, e-cigarettes produce ultrafine particles than can trigger inflammatory problems and lead to heart and lung disease.

“The data is just becoming overwhelming,” Glantz said.

E-cigarettes expose people to more than ‘harmless water vapor’

E-cigarettes are billed as producing “harmless water vapor,” but, strictly speaking, the vapor produced when users exhale is actually an aerosol that contains a mixture of nicotine, flavorings and other ingredients that can be toxic.

Stanford University pediatrics professor Bonnie Halpern-Felsher has studied young people’s perceptions of e-cigarettes. In September, she launched a free, downloadable youth tobacco prevention toolkit with an e-cigarette module, funded by the UC Tobacco-Related Disease Research Program (TRDRP) and the California Department of Education.

“Youth are definitely using e-cigarettes because they think they are cool,” Halpern-Felsher said. “Adolescents and young adults don’t know a lot about e-cigarettes. They think it’s just water or water vapor. They don’t understand it’s an aerosol. They don’t understand that e-cigarettes can have nicotine. They don’t understand that flavorants themselves can be harmful.”

The flavors can be toxic

More than 7,000 varieties of flavored e-cigarettes are on the market.

UC Riverside professor of cell biology Prue Talbot screened the cytotoxicity (quality of being toxic to cells) of 36 refill fluids and found that some were highly toxic. The most cytotoxic flavor, Cinnamon Ceylon, contained a chemical called cinnamaldehyde, which gives cinnamon its flavor and whose side effects may include coughing and sore throats. Talbot has been studying more flavors and is building a database to help determine the most dangerous ones.

“Flavors are something that could be potentially regulated,” Talbot said.

Vaping has secondhand and thirdhand effects

Unlike cigarettes, which emit smoke from the lit end, e-cigarettes don’t produce sidestream emissions between puffs, but they still generate secondhand and thirdhand effects when users exhale the mainstream vapor.

In a TRDRP-funded study, Berkeley Lab researcher Hugo Destaillats led a team that found 31 chemicals that include several toxicants at significant levels in e-cigarette vapor. The most toxic chemicals included acrolein, a severe eye and respiratory irritant; and formaldehyde, an irritant and probable carcinogen.

Emissions varied by type of device and voltage.

“The way you heat the liquid drastically determines if you produce a lot of compounds or just a few,” Destaillats said. “As you increase the voltage, toxic byproduct concentrations increase exponentially.”

The batteries can explode

There were 134 reports of e-cigarette batteries overheating, catching fire or exploding between 2009 and January 2016, according to the Food and Drug Administration, which will host a public workshop in April to gather information about e-cigarette battery safety concerns.

Calls to poison control centers about e-cigarette exposure in young children have skyrocketed nationally in recent years. In California, the number of calls involving e-cigarettes increased from 19 in 2012 to 243 in 2014, according to the UC-administered California Poison Control System. More than 60 percent of those e-cigarette calls were related to nicotine poisoning in children 5 and under.

E-cigarettes show mixed results in helping smokers quit

While some people have quit smoking with e-cigarettes, on average, adult smokers who use e-cigarettes are about 30 percent less likely to stop smoking cigarettes, Glantz said. Also, e-cigarettes are associated with more, not less, cigarette smoking among adolescents.

“If you are a middle-aged person who has been smoking for 20 years, maybe it is good to switch to e-cigarettes,” Destaillats said. “But if you are a teenager and never have smoked, then it is not a good idea to use e-cigarettes.”

The minimum age has risen

In June, California became the nation’s second state, following Hawaii, to raise the minimum age for tobacco sales to 21, and for the first time added e-cigarettes to the definition of tobacco products. In August, the FDA extended its tobacco oversight to e-cigarettes, banning sales to those under 18.

“It sends a message to youth that e-cigarettes are in the same category of all tobacco products,” Halpern-Felsher said.

E-cigarettes will be taxed

Under Proposition 56, the tobacco tax passed by California voters in November, the state will tax e-cigarettes for the first time, starting April 1. It’s estimated that the price of a typical 30-milliliter bottle of e-liquid could increase to about $30 from $20.

“Anytime you increase the price, people buy less,” Glantz said.

The tax revenue will enhance education efforts by boosting funding for the state Tobacco Control Program. The surgeon general’s report also will make it easier for states to integrate e-cigarettes into tobacco education campaigns and could lead to more regulations, Glantz said.

E-cigarettes may be safer than cigarettes, but unknown risks remain

Expect more information to emerge about e-cigarettes as studies examine long-term effects.

“It’s often assumed that e-cigarettes are safer than cigarettes, but that could be an incorrect assumption,” Talbot said. “We don’t yet know the long-term health effects of e-cigarettes.”

Decades of research have helped scientists determine that cigarette smoke creates more than 7,000 chemicals, at least 69 of which are known to cause cancer and many of which are poisonous.

So, while e-cigarettes deliver fewer cancer-causing chemicals than cigarettes, research has yet to reveal how e-cigarettes fully impact heart and lung health and their cancer-causing potential, Glantz said.

He estimates that e-cigarettes are about one-third to one-half as dangerous as cigarettes.

California voters soundly approved a ballot measure Tuesday to raise tobacco taxes $2 a pack and start taxing electronic cigarettes, marking what supporters called a victory for public health that overcame a heavily financed fight by tobacco companies.

The measure passed by a margin of 63 percent to 37 percent with more than 5.6 million votes counted.

Opponents, led by tobacco companies, poured more than $71 million into efforts to defeat Proposition 56, compared to more than $34 million raised by supporters of the initiative that included billionaire environmentalist Tom Steyer.

“This historic measure will reduce teen smoking, fund the health care system, and save lives,” Steyer said in a statement. “Californians rejected the tobacco industry’s lies and acted to protect the health of our kids.”

The measure will add $2 to the current 87-cents-a-pack state tax on cigarettes. California also joins only about a half dozen states in taxing e-cigarettes, including vapor products. Proponents of taxing such products hoped approval would prompt more states to follow the trendsetting California.

Anti-smoking advocates said the vapor liquids that come in candy flavors aim to hook a new generation on nicotine, while the vaping industry argued its products are a safer alternative to smoking tobacco and expressed concern that taxing them at the same rate as tobacco products could threaten them as a potentially useful tool to help smokers quit.

E-cigarettes heat liquid nicotine into a vapor, delivering the chemical that smokers crave without the harmful by-products generated from burning tobacco. Some say e-cigarettes are a potentially useful tool to help smokers — a benefit that could be threatened if the products are taxed.

California has not raised its tobacco taxes since 1998.

Besides Steyer, Proposition 56 drew support from medical groups, educators and former New York City Mayor Michael Bloomberg, who also supported a failed attempt to raise tobacco taxes in 2012. It was narrowly defeated amid big spending by tobacco interests.

California’s legislative analyst and the state’s finance director said Proposition 56 could raise $1 billion to $1.4 billion in state revenue by the 2017-2018 year, with potentially lower annual revenues over time.

Tobacco companies said the money will benefit insurance companies and hospital corporations. The industry was accused of misleading voters with that campaign because much of the money, in fact, will go to California’s Medi-Cal, the state-run program that pays insurance providers and hospitals for low-income residents. The tax revenue would also fund anti-smoking campaigns and medical research.

“Since day one, we ran our campaign on the issues and substance of the measure, and urged voters to evaluate the content, intent and flaws of Prop. 56,” Beth Miller, spokeswoman for the “No on 56” campaign, said in a statement. “While we believe Proposition 56 is bad public policy, the voters have spoken and we respect their decision.”

Both California and Hawaii recently increased the legal age to 21 to purchase either tobacco or e-cigarettes.

The Excise Department may ask the government to allow the legal import of electronic cigarettes and baraku, which would be taxed like cigarettes, says director-general Somchai Poolsavasdi.

He said the department has noticed a loophole in the current tobacco law, which does not define these products as new types of tobacco-related goods intended to replace conventional cigarettes.

“We are still uncertain whether we will allow them to be imported legally or not, but if we decide to allow it we will have to tax them for sure,” said Mr Somchai.

“We have decided to take the first step to treat them properly by adjusting the legal definition of tobacco to cover all of these items. It not only concerns electronic cigarettes and baraku, but everything that has been created to be consumed in place of cigarettes,” he added.

Under the Tobacco Act 1966, tobacco products are defined as those made from tobacco leaf only, hence, it cannot govern cigarettes in electronic form or water pipes, also known as baraku, which are also now available in electronic form.

“Once we define these goods as taxable items, it will be easier for us to tax them later if we allow them to be imported legally,” said Mr Somchai.

While new ways of smoking and vaping have been available on markets worldwide for years, it is illegal to import such items into Thailand, resulting in them being smuggled in.

“It is quite complicated as tobacco is a sensitive issue here. We have to study thoroughly the pros and cons of allowing them to be imported legally,” he said.

It is still debatable whether e-cigarettes or baraku are healthier alternatives to cigarettes and cigars.

The amended law on excise tax has been passed by the Council of State after earlier being approved by the cabinet. It is now under consideration of the National Legislative Assembly. If the NLA approves the revised law, it will come into effect 180 days after it is announced in the Royal Gazette.

The excise tax restructuring is part of the Finance Ministry’s comprehensive tax reforms, while the Tobacco Act is a part of the tax reform plan. The legal amendments will switch the excise tax basis to state-recommended retail prices from ex-factory prices. The change is expected to come into force by mid-2017.

Switching the method of calculation will standardise duty collection and create more fairness and transparency, said the director-general.

Under the current system of calculating excise tax, importers have used loopholes to understate the value of costs, insurance and freight (CIF) in order to reduce their tax burdens.

But the excise duty calculation based on state-recommended retail prices will make it harder for importers to evade making tax payments, said Mr Somchai.

Even though state-recommended retail prices are normally higher than ex-factory prices and CIF value, he said the change will not further burden importers, as the Excise Department will mitigate the effects by lowering the current rates.

Apart from the Tobacco Act, six other laws will be integrated into a single act to standardise and simplify the tax collection process to facilitate the new tax calculation structure.

They are the Liquor Act of 1950, the Playing Card Act of 1943, the Excise Tariff Act of 1984, the Excise Tax Act of 1984, the Allocation of Excise Tax Act of 1984 and the Allocation of Liquor Tax Act of 1984.

EU countries are preparing to tax e-cigarettes under the same regime as normal cigarettes, in a move likely to increase prices and to prompt a fight by lobbyists in Brussels.

Last Friday (26 February), member states’ ambassadors agreed to take the first step by asking the European Commission to draft an “appropriate legislative proposal” in 2017.

The project is to be endorsed without further discussion when the bloc’s finance ministers meet on 8 March.

The ministers’ draft conclusions said that e-cigarettes, as well as other “novel” products, could cause “inconsistencies and legal uncertainty” in the single market if they stayed exempt from excise tax.

They also said excise duties or some “other specifically designed tax” on novel tobacco items, which use steam instead of smoke to put nicotine into people’s lungs, could help meet “public health objectives”.

They added that work on the new tax regime should be “intensified” if “the market share of such products show a tendency to increase”.

Prices ‘will rise’

Global e-cigarette sales were about €7.5 billion last year. But analysts forecast they will grow to €46 billion by 2025 or 2030.

Under existing rules, all EU countries must impose an excise tax of at least 57 percent on tobacco products, but most impose only VAT on e-cigarettes at a level of about 20 percent.

In the UK the excise and VAT burden sees the state collect £6.17 every time someone pays the recommended retail price of £7.98 for a pack of 20 premium-brand cigarettes.

The excise income alone is worth €15.5 billion a year.

One EU official said on Monday (29 February) it was “self-evident” that the price of e-cigarettes would go up if the commission went ahead. A second official said it was “too early to say what effect the review” of excise rules might have on prices.

The ministers’ draft conclusions noted that the commission was not obliged to go ahead. But the draft text said EU states would want “reasons” if it did not act.

With several EU capitals still struggling to balance the books, the commission in a report in December also said e-cigarette taxes could have “significant long term budgetary implications” for national treasuries.

Lobbying war

One of the EU officials said the next steps would be “to undertake studies, carry out impact assessments, [and] a public consultation”, setting the stage for a new lobbying war in Brussels.

The last time the EU regulated e-cigarettes, in 2014, big tobacco firms led by Philip Morris International (PMI) tried to dilute the new restrictions on grounds that e-cigarettes help people to quit smoking.

They did it because they were buying up e-cigarette makers to protect their profits.

E-cigarette firms joined them in what Olivier Hoedeman, from Corporate Europe Observatory (CEO), a Brussels-based pro-transparency NGO, called an “angry” campaign with “very strong emotions”.

One MEP at the time got an email saying she would be “finished” if she obstructed e-cigarettes.

EUobserver received emails saying it would be responsible for smokers’ deaths if it published stories giving credence to claims that e-cigarettes are bad for your health.

On the other side, pharmaceutical giants such as GlaxoSmithKline lobbied for tougher EU rules on the grounds that e-cigarettes encouraged young people to start smoking.

They did it because they make nicotine gums and patches, which compete with e-cigarettes for people trying to give up. But gums and patches are regulated under more exacting EU medical product standards.

They were joined by companies such as Trierenberg-Gruppe, the world’s top producer of cigarette papers.

More research needed

Public health advocates such as Cancer Research UK and the European Heart Network are concerned that the corporate lobbyists are ignoring science.

Most health NGOs do not have a position on e-cigarettes because they are too new for conclusive research on long-term benefits and risks.

The European Network for Smoking and Tobacco Prevention, a Brussels-based group, is calling for tougher EU rules.

But its spokesman, Dominick Nguyen, told EUobserver: “This is not about being for or against e-cigarettes, but [about] encouraging research and provision of evidence on e-cigarettes in order to make the right informed decisions.”

Commenting on the “public health” aspect of the excise tax project, CEO’s Hoedeman said: “It would be quite awkward to put e-cigarettes in the same category [as normal cigarettes] if the science isn’t there yet”.

PMI was not available for comment on Monday. GlaxoSmithKline declined to comment.

According to their public declarations, PMI spent up to €1.5 million lobbying EU officials in 2014. GlaxoSmithKline spent up to €2 million.